Can Health Insurance Claims Be Denied?

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Written by PolicyBazaar

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Modified 16 November 2016

Health insurance is the need of the hour. Developments in medicine have increased the life expectancy of an average human. Coupled with it, the fast-paced lifestyle of modern generation has increased the incidence rate of ailments and diseases.

If we add the rising medical costs to this equation, the result only states the obvious – disaster! There is only one hope of battling out the highly probable medical costs that would befall us and that hope is a health insurance policy.

Perhaps, people have imagined the aftermath of a medical complication and that is why awareness of a health insurance policy is very high. The benefits of from a health insurance claim should compensate the substantial hospital bills accrued in the event of a medical emergency and as such becomes the lifeline of many individuals.

It may sound like bursting your bubble, but, your health insurance claim might be denied. Though the insurance company strives to fulfill the claims raised, there are certain instances which may result in a denial of claim settlement.

Reasons For Denial of Health Insurance Claim Settlement:

Misrepresentation or non-disclosure of material facts:

Though we blame the insurer if the health insurance claim is denied, do we ever blame ourselves? A health insurance policy is issued on the understanding that the proposer has stated all his required details truthfully and correctly in the proposal form. This is in compliance to the Principle of Utmost Good Faith which is the basis of all insurance contracts. Based on your stated facts, underwriting is done by which the insurer evaluates the risk you present. If you hide important information or lie about any medical condition you suffer from, you are in a diabolical position. In case of a claim, the insurer determines the cause of the claim and if it is discovered that the claim arose because you hid or lied about an important fact, the company has the authority to reject your claim.

Incorrect health insurance claim procedure:

The insurance provider prescribes certain steps which the policyholder is required to follow when making a claim. Informing the insurer of the emergency, seeking treatment in a recognized hospital, filling up the required claim form, attaching all the relevant bills and reports are some of the required things to do for making a claim. If your claim filing is improper or incorrect, your claim stands to be denied

Health insurance claims for permanent exclusions :

Every health insurance plan has an exclusion list, incidences which are excluded from the scope of coverage. These are the permanent exclusions and any claim made in respect of these excluded instances would be denied.

Health insurance claims for temporary exclusions:

Pre-existing ailments have a waiting period and there are other ailments which are covered only after a prescribed waiting period. Claims raised for such exclusions which have a waiting period during the waiting period would be denied

Claims on lapsed policies:

If you delay in paying the premium beyond the due date, the policy will lapse. A lapsed policy pays no claim so, even if it has been 2 or 4 days since a lapse, your claim would be denied.

How can you avoid health Claim Rejection?

Full disclosure

Yes, stating every personal detail asked, even if it is unfavorable is in your interests. It may increase your premium outgo if you have any existing ailment, but you would be ensured of your claims to be honored.

Following the claim procedure

After you buy the plan, you should be fully conversant in the steps to be followed for raising a valid claim. Seek the help of your broker if needed because the broker can guide you properly.

Renew your plan every year

Though you might not face a claim as soon as you buy a health plan, someday you would. When disaster strikes, you need a valid plan to pay the related expenses. You should, thus, renew your plan every year to ensure a continued coverage.

So, now you know why your claim can be rejected and how you can avoid it. Be aware and follow the guidelines to ensure that your health insurance claims get honored.

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*The information provided on this website/page is only for information sake. Policybazaar does not in any form or manner endorse the information so provided on the website and strives to provide factual and unbiased information to customers to assist in making informed insurance choices.